Provider Demographics
NPI:1720031172
Name:ROBERTSON, SANDRA D (ARNP)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:D
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 CRANES ROOST CT
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-3650
Mailing Address - Country:US
Mailing Address - Phone:270-769-1304
Mailing Address - Fax:270-234-8028
Practice Address - Street 1:1311 N DIXIE HWY
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-2621
Practice Address - Country:US
Practice Address - Phone:270-769-1304
Practice Address - Fax:270-234-8028
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2008-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4725P363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY30605018Medicaid
KY000000480985OtherANTHEM
11571509OtherCAQH
KY0358997Medicare PIN
KY0358795Medicare PIN
KY00201002Medicare PIN
KY0359295Medicare PIN
KY000000480985OtherANTHEM
KYQ78073Medicare UPIN
KY0358695Medicare PIN